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STATE OF CALIFORNI WATER RESOURCES CONTRC 30ARD FORM 'B': UNDMGROUND STORAGE TANK PRO*RAM >� a TANK TANK PERMIT APPLICATION INFORMATION COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. -- Z 10 MARK ONLY ❑ 1 NEW PERMIT ❑3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED TANK ONE ITEM F-12 INTERIM PERMIT ❑4 AMENDED PERMIT ❑6 TEMPORARY TANK CLOSURE ❑y' TO9ANK REMOVED W FACILITY/SITE NAME WHERE TANK IS INSTALLED: n FARM TANK-YES❑ NO N Ca I. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN-SO SPECIFY {� A. OWNERS TANK ID# B. MANUFACTURED BY: - C. YEARINSTALLED D. TANK CAPACITY IN GALLONS: 11. TANK CONTENTS IF(A.1),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. A. 1 MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. UNLEADED ❑ 2 LEADED ❑ 3 DIESEL ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT ❑4 GASAHOL ❑ 5 JET FUEL ❑6 AVIATION GAS ❑ 5 HAZARDOUS ❑ BO EMPTY ❑ 95 UNKNOWN ❑ 2 WASTE ❑7 METHANOL ❑ 99 OTHER(DESCRIBE IN ITEM D,BELOW) D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF HAZARDOUS SUBSTANCE STORED&C.A.S.# C.A.S.W Ill. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOX A,B,C,AD A. TYPE OF ❑1 DOUBLE WALLED ❑ 3 SINGLE WALLED WITH EXTERIOR UNEP NKNOWN SYSTEM ❑ 2 SINGLE WALLED ❑4 SECONDARY CONTAINMENT ❑ 99 OTHER ❑ 1 STEEUIRON ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC B. TANK ❑ 5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑7 ALU UM ❑ 8100%METHANOL COMPATIBLE FOP MATERIAL ❑9 BRONZE ❑70 GALVANIZED STEEL95 UNKNOWN ❑ 99 OTHER C. INTERIOR ❑ 1 RUBBER LINED ❑2 ALKYD LINING ❑3 EPDXY LINING n 4 PHEI4O�IC LINING LINING ❑5 GLASS UNING ❑6 UNLINED 95/UNKNOWN ❑ IS LINING MATERIAL COMPATIBLE WITH IDB%METHANOL? ❑YES ❑NOOTRE lr I A D. CORROSION ❑ 1 POLYETHLENE WRAP ❑2 TAR OR ASPHALT ❑3 VINYL WRAP ❑4 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑5 CATHODIC PROTECTION ❑91 NONE #KNOWN ❑99 OTHER IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE A SYSTEM TYPE A U i SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U- 5 UNKNOWN A U 99 OTHER S.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE A U 5 UNKNOWN A U 99 OTHER A U 1 STEELARON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE C. MATERIAL A U 5 ALUMINUM A 8 CONCRETE A U 7 STEELCLADW/FRP A U 8 100%METHANOL COMPATIBLE FRP A U 9 GALVANIZED STEEL U 95 UNKNOWN A U 99 OTHER V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. P 8 1VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3VADOSE WELLS S 4 ELECTRONIC MONITOR P 8 5 GROUND WATER MONITORING WELLS P 8 6 PRECISION TESTING P 8 7 PRESSURE TESTING P 8 91 NONE P- 8 95 UNKNOWN P 8 99 OTHER VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE 1. ESTIMATED DATE LAST USED(MO/YR 2. ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH SUBSTANCE REMAINING IN GALLONS INERT MATERIAL? ❑YES [:] NO THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. APPLICANT'S NAME(PRINTED&SIGNATURE) DATE LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# AGENCY# FACILITY ID# TANK ID# ® E= I DI ol HL= I ol o CURRENT LOCAL AGENCY FACILITY 10 N ��1 1 O APPROVED BY NAME PHONE N WITH AREA CODE OA ( PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE CHECK# PERMIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT# BY: FORM 0(6-29-66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS, ,4RRENT FORMA HAS BEEN FILED DATA PROCESSING COPY